Whether revisions to the bible of mental illness should be carried out in secret might seem like an academic question.
But the issue carries real weight for parents desperate to address children's difficult behavior or people in distress over their mental state. It also speaks to citizens' concerns over news accounts of an overmedicated America and of the troubling financial links between some psychiatric researchers and the pharmaceutical industry.
An update is underway for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM, which defines the emotional problems for which doctors prescribe drugs and insurance companies pay the treatment bills. Psychiatrists working on the new edition were required to sign a strict confidentiality agreement.
Critics contend that the American Psychiatric Assn. should allow outside observers to review the scientific debate behind new and revised diagnoses.
Among the most prominent to speak out is the editor of the manual's third edition, Dr. Robert Spitzer, hailed by peers as the most influential psychiatrist of his generation. If the DSM is often called the profession's bible, then the DSM-III is the King James Version. Released in 1980, it set the standard by which others are measured.
Recently, Spitzer broke ranks by publishing an open letter to the profession protesting the confidentiality mandate.
"If you don't know what goes on at someone's meetings, they're suspect of having a conflict of interest," the Columbia University professor said in an interview.
The profession is already confronting that issue through revelations that academics in the field are earning tens of thousands of dollars in consulting fees from drug companies. The financial links between the drug industry and the psychiatric community have sparked a congressional investigation headed by Sen. Charles E. Grassley (R-Iowa).
Officials with the APA counter that the psychiatrists working on the DSM revision are limited to $10,000 annually in fees from drug companies. The association says "transparency" is the byword of those overseeing the process.
Darrel Regier, who heads the APA's research arm, said the critics are failing to recognize progress in the field. "The field of psychiatry has gone from an ideology to a scientific pursuit," he said. The DSM grew out of a guidebook used by the military during World War II. Afterward, it was revised for general use and subsequently enlarged.
When it first appeared in the 1950s, psychiatry was dominated by Freud's model of psychological suffering, one that was resolvable by talking out the conflict with a therapist. Yet even then, drugs were appearing for relief of psychotic symptoms, and leadership in the profession has since passed to psychiatrists with an alternative model: biology and genetics as the source of emotional problems.
As the field has changed, the number of disorders in the DSM has tripled to 300, an increase paralleled by the rise in sales of drugs that pharmaceutical companies and psychiatrists tout as remedies for emotional suffering.
Some critics suspect that a quest for profits has encouraged the field to create mental illnesses out of personality quirks.
In his recent book, "Shyness: How Normal Behavior Became a Sickness," Christopher Lane traces how shyness morphed from a character trait into a pathological condition called "social phobia," which the DSM defines as "fears that he or she may do something or act in a way that will be humiliating or embarrassing." With disorders so broadly drawn, Lane wonders, who among us is sane?
It's an apt criticism, says David Kupfer, who is shepherding the DSM's revision.
"One of the raps against psychiatry is that you and I are the only two people in the U.S. without a psychiatric diagnosis," said Kupfer, head of the psychiatry department at the University of Pittsburgh.
Kupfer said he hopes to reduce the number of diagnostic categories in the forthcoming edition of the DSM, scheduled to appear in 2012.
He argues that scientific progress comes from formulating ideas, then seeing if others can shoot them down. If currently listed maladies fail that test, they'll be dropped, Kupfer said.
Meanwhile, Lane -- who has become something of a thorn in the side of the psychiatric community -- has irked some by obtaining the working papers of psychiatrists who produced the DSM-III and making plans to post them on his website.
Some of his finds read less like scientific discourse than like shtick from a Catskills comedian.
One syndrome under discussion at the time was "chronic complaint disorder."
Its supposed sufferers were largely "of Eastern European ancestry" and revealed their malady when asked how things are going.
"In those cases," the psychiatrists wrote, "the pathognomonic expression becomes, 'Oy vey, don't ask.' "
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About the new edition
What is it? The DSM is the authoritative psychiatric handbook defining mental disorders.
What's new? The American Psychiatric Assn. is revising it. The new version is expected in 2012.
Why does it matter? Prescriptions for psychiatric drugs are written in accordance with the DSM. Courts, social workers and insurance companies also use it in their decisions.
Why the fuss? Authors of the forthcoming fifth edition are pledged to secrecy, leading others to question whether science should be done behind closed doors. Disclosures of financial links between psychiatrists and drug companies raise the question: Is this a search for truth or for profits? Meanwhile, critics worry we're becoming a nation too quick to reach for pills.